CARIN Consumer Directed Payer Data Exchange
0.1.0 - STU1
CARIN Consumer Directed Payer Data Exchange
0.1.0 - STU1
CARIN Consumer Directed Payer Data Exchange - Local Development build (v0.1.0). See the Directory of published versions
The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at a facility as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services as form CMS-1450.
The official URL for this profile is:
http://hl7.org/fhir/us/carin-bb/StructureDefinition/CARIN-BB-ExplanationOfBenefit-Inpatient-Facility
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CARINBBExplanationOfBenefit
Summary
Mandatory: 5 elements (8 nested mandatory elements)
Must-Support: 6 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from CARINBBExplanationOfBenefit
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ExplanationOfBenefit | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource | |
  type | 1..1 | CodeableConcept | Category or discipline | |
  coding | S | 1..1 | Coding | Code defined by a terminology system |
  code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: institutional | |
  provider | 1..1 | Reference(CARIN BB Organization) | Party responsible for the claim | |
| careTeam | 0..* | BackboneElement | Care Team members | |
| role | 1..1 | CodeableConcept | Function within the team Binding: Payer - Inpatient Facility Provider Role (required) | |
 supportingInfo | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:$this | |
  supportingInfo:billingnetworkcontractingstatus | 0..1 | BackboneElement | Claim performing provider network status | |
  category | 1..1 | CodeableConcept | Classification of the supplied information | |
 coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: billingnetworkcontractingstatus | |
 code | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) | |
| supportingInfo:attendingnetworkcontractingstatus | 0..1 | BackboneElement | Claim attending provider network status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: attendingnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) | |
| supportingInfo:referringnetworkcontractingstatus | 0..1 | BackboneElement | Claim attending provider network status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: referringnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) | |
| supportingInfo:clmrecvddate | 0..1 | BackboneElement | Claim Received Date | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: clmrecvddate | |
 timing[x] | 1..1 | date | When it occurred | |
| supportingInfo:typeofbill | 0..1 | BackboneElement | Type of Bill | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: typeofbill | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Type of Bill (required) | |
| supportingInfo:pointoforigin | 0..1 | BackboneElement | Claim Point of Origin for Admission or Visit | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: admsrc | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Point of Origin of Admission (required) | |
| supportingInfo:admtype | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: admtype | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) | |
| supportingInfo:discharge-status | 0..1 | BackboneElement | Discharge Status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: discharge-status | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) | |
 supportingInfo:ms-drg | 0..1 | BackboneElement | Claim diagnosis related group (DRG), including the code system, the DRG version and the code value | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: ms-drg | |
| code | 0..1 | CodeableConcept | Type of information Binding: MS-DRG (required) | |
| diagnosis | S | 1..* | BackboneElement | Pertinent diagnosis information |
| diagnosis[x] | S | 1..1 | (Slice Definition) | Nature of illness or problem Slice: Unordered, Open by type:$this |
| diagnosisCodeableConcept | 0..1 | CodeableConcept | Nature of illness or problem Binding: ICD-10-CM Diagnosis Codes (required) | |
| type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | S | 0..1 | CodeableConcept | Present on admission Binding: NUBC Present On Admission (required) |
| item | 0..* | BackboneElement | Product or service provided | |
| revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: NUBC Revenue Code (required) | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: AMA CPT and CMS HCPCS Procedure Codes (required) | |
| modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: AMA CPT and CMS HCPCS Modifier Codes (required) | |
| adjudication | 0..* | (Slice Definition) | Adjudication details Slice: Unordered, Closed by pattern:$this | |
| adjudication:adjudicationamounttype | 0..* | BackboneElement | Amounts | |
 category | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Value Codes (required) | |
| amount | 1..1 | Money | Monetary amount | |
| adjudication:denialreason | 0..1 | BackboneElement | Denial Reason | |
| category | 1..1 | CodeableConcept | Type of adjudication information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: denialreason | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) | |
| adjudication:allowedunits | 0..1 | BackboneElement | Allowed number of units | |
 category | 1..1 | CodeableConcept | Type of adjudication information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: allowedunits | |
| adjudication | 1..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by pattern:$this | |
| adjudication:All Slices | Content/Rules for all slices | |||
 category | S | 1..1 | CodeableConcept | Type of adjudication information |
| adjudication:adjudicationamounttype | 0..* | BackboneElement | Amounts | |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Value Codes (required) | |
| amount | 1..1 | Money | Monetary amount | |
| adjudication:denialreason | 0..1 | BackboneElement | Denial Reason | |
| category | 1..1 | CodeableConcept | Type of adjudication information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: denialreason | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) | |
| adjudication:inoutnetwork | 1..1 | BackboneElement | Benefit Payment Status | |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Benefit Payment Status (required) | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: inoutnetwork | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | I | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource |
| id | Σ | 0..1 | string | Logical id of this artifact |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| id | 0..1 | string | Unique id for inter-element referencing | |
 extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| versionId | ΣI | 0..1 | id | Version specific identifier |
| lastUpdated | SΣI | 1..1 | instant | When the resource version last changed |
| source | ΣI | 0..1 | uri | Identifies where the resource comes from |
| profile | SΣI | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| security | ΣI | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible) |
| tag | ΣI | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example) |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | I | 1..* | (Slice Definition) | Business Identifier for the resource Slice: Unordered, Open by pattern:$this |
| identifier:All Slices | Content/Rules for all slices | |||
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | SΣI | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | ΣI | 0..1 | string | The value that is unique Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| identifier:claimnumber | SI | 1..1 | Identifier | Claim Number |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: cn | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | The value that is unique Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| status | ?!ΣI | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required) |
| type | SΣI | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: institutional |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| subType | I | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example) |
| use | ΣI | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required) Required Pattern: claim |
| patient | SΣI | 1..1 | Reference(CARIN BB Patient) | The recipient of the products and services |
| billablePeriod | SΣI | 0..1 | Period | Relevant time frame for the claim |
| created | ΣI | 1..1 | dateTime | Response creation date |
| enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
| insurer | SΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for reimbursement |
| provider | SΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for the claim |
| priority | I | 0..1 | CodeableConcept | Desired processing urgency Binding: http://terminology.hl7.org/CodeSystem/processpriority (example) |
| fundsReserveRequested | I | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example) |
| fundsReserve | I | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example) |
| related | SI | 0..* | BackboneElement | Prior or corollary claims |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| claim | I | 0..1 | Reference(Claim) | Reference to the related claim |
| relationship | SI | 1..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example) |
| reference | I | 0..1 | Identifier | File or case reference |
| prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products |
| originalPrescription | I | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller |
| payee | SI | 0..1 | BackboneElement | Recipient of benefits payable |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SI | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Code (required) |
| party | SI | 1..1 | Reference(CARIN BB PractitionerRole | CARIN BB Patient) | Recipient reference |
| referral | I | 0..1 | Reference(ServiceRequest) | Treatment Referral |
| facility | I | 0..1 | Reference(Location) | Servicing Facility |
| claim | I | 0..1 | Reference(Claim) | Claim reference |
| claimResponse | I | 0..1 | Reference(ClaimResponse) | Claim response reference |
| outcome | ΣI | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
| disposition | I | 0..1 | string | Disposition Message |
| preAuthRef | I | 0..* | string | Preauthorization reference |
| preAuthRefPeriod | I | 0..* | Period | Preauthorization in-effect period |
| careTeam | SI | 0..* | BackboneElement | Care Team members |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Order of care team |
| provider | SI | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization |
| responsible | SI | 0..1 | boolean | Indicator of the lead practitioner |
| role | SI | 1..1 | CodeableConcept | Function within the team Binding: Payer - Inpatient Facility Provider Role (required) |
| qualification | I | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example) |
| supportingInfo | SI | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:$this |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
 timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:billingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Claim performing provider network status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: billingnetworkcontractingstatus |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:attendingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Claim attending provider network status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: attendingnetworkcontractingstatus |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:referringnetworkcontractingstatus | SI | 0..1 | BackboneElement | Claim attending provider network status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: referringnetworkcontractingstatus |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:clmrecvddate | SI | 0..1 | BackboneElement | Claim Received Date |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: clmrecvddate |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | SI | 1..1 | date | When it occurred |
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:typeofbill | SI | 0..1 | BackboneElement | Type of Bill |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: typeofbill |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Type of Bill (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:pointoforigin | SI | 0..1 | BackboneElement | Claim Point of Origin for Admission or Visit |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: admsrc |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Point of Origin of Admission (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:admtype | SI | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: admtype |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:discharge-status | SI | 0..1 | BackboneElement | Discharge Status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: discharge-status |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:ms-drg | SI | 0..1 | BackboneElement | Claim diagnosis related group (DRG), including the code system, the DRG version and the code value |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: ms-drg |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: MS-DRG (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| diagnosis | SI | 1..* | BackboneElement | Pertinent diagnosis information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Diagnosis instance identifier |
| diagnosis[x] | SI | 1..1 | (Slice Definition) | Nature of illness or problem Slice: Unordered, Closed by type:$this Binding: ICD-10Codes (example) |
| diagnosis[x]:diagnosisCodeableConcept | I | 0..1 | CodeableConcept | Nature of illness or problem Binding: ICD-10-CM Diagnosis Codes (required) |
| type | SI | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | SI | 0..1 | CodeableConcept | Present on admission Binding: NUBC Present On Admission (required) |
| packageCode | I | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example) |
| procedure | SI | 0..* | BackboneElement | Clinical procedures performed |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Procedure instance identifier |
| type | SI | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example) |
| date | SI | 0..1 | dateTime | When the procedure was performed |
| procedure[x] | SI | 1..1 | (Slice Definition) | Specific clinical procedure Slice: Unordered, Closed by type:$this Binding: ICD-10ProcedureCodes (example) |
| procedure[x]:procedureCodeableConcept | I | 0..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10-PCS (required) |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| precedence | I | 0..1 | positiveInt | Precedence (primary, secondary, etc.) |
| insurance | SΣI | 1..* | BackboneElement | Patient insurance information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | SΣI | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | SΣI | 1..1 | Reference(CARIN BB Coverage) | Insurance information |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| accident | I | 0..1 | BackboneElement | Details of the event |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| date | I | 0..1 | date | When the incident occurred |
| type | I | 0..1 | CodeableConcept | The nature of the accident Binding: V3 Value SetActIncidentCode (extensible) |
| location[x] | I | 0..1 | Where the event occurred | |
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| item | SI | 0..* | BackboneElement | Product or service provided |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Item instance identifier |
| careTeamSequence | I | 0..* | positiveInt | Applicable care team members |
| diagnosisSequence | I | 0..* | positiveInt | Applicable diagnoses |
| procedureSequence | I | 0..* | positiveInt | Applicable procedures |
| informationSequence | I | 0..* | positiveInt | Applicable exception and supporting information |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: NUBC Revenue Code (required) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: AMA CPT and CMS HCPCS Procedure Codes (required) |
| modifier | I | 0..* | CodeableConcept | Product or service billing modifiers Binding: AMA CPT and CMS HCPCS Modifier Codes (required) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| encounter | I | 0..* | Reference(Encounter) | Encounters related to this billed item |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | SI | 0..* | (Slice Definition) | Adjudication details Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | SI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Value Codes (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 1..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | SI | 0..1 | BackboneElement | Denial Reason |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: denialreason |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:allowedunits | SI | 0..1 | BackboneElement | Allowed number of units |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: allowedunits |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| detail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Detail level adjudication details |
| subDetail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Subdetail level adjudication details |
| addItem | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | I | 0..* | positiveInt | Item sequence number |
| detailSequence | I | 0..* | positiveInt | Detail sequence number |
| subDetailSequence | I | 0..* | positiveInt | Subdetail sequence number |
| provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| detail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| subDetail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| adjudication | SI | 1..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | SI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Value Codes (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 1..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | SI | 0..1 | BackboneElement | Denial Reason |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: denialreason |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:inoutnetwork | SI | 1..1 | BackboneElement | Benefit Payment Status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Benefit Payment Status (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: inoutnetwork |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| total | ΣI | 0..* | BackboneElement | Adjudication totals |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Amount Category (extensible) |
| amount | ΣI | 1..1 | Money | Financial total for the category |
| payment | SI | 0..1 | BackboneElement | Payment Details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 0..1 | CodeableConcept | Partial or complete payment Binding: Claim Payment Status Code (required) |
| adjustment | I | 0..1 | Money | Payment adjustment for non-claim issues |
| adjustmentReason | I | 0..1 | CodeableConcept | Explanation for the variance Binding: Adjudication Denial Reason (extensible) |
| date | I | 0..1 | date | Expected date of payment |
| amount | I | 0..1 | Money | Payable amount after adjustment |
| identifier | I | 0..1 | Identifier | Business identifier for the payment |
| formCode | I | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example) |
| form | I | 0..1 | Attachment | Printed reference or actual form |
| processNote | I | 0..* | BackboneElement | Note concerning adjudication |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| number | I | 0..1 | positiveInt | Note instance identifier |
| type | I | 0..1 | code | display | print | printoper Binding: NoteType (required) |
| text | I | 0..1 | string | Note explanatory text |
| language | I | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| benefitPeriod | I | 0..1 | Period | When the benefits are applicable |
| benefitBalance | I | 0..* | BackboneElement | Balance by Benefit Category |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| excluded | I | 0..1 | boolean | Excluded from the plan |
| name | I | 0..1 | string | Short name for the benefit |
| description | I | 0..1 | string | Description of the benefit or services covered |
| network | I | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example) |
| unit | I | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example) |
| term | I | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example) |
| financial | I | 0..* | BackboneElement | Benefit Summary |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example) |
| allowed[x] | I | 0..1 | Benefits allowed | |
| allowedUnsignedInt | unsignedInt | |||
| allowedString | string | |||
| allowedMoney | Money | |||
| used[x] | I | 0..1 | Benefits used | |
| usedUnsignedInt | unsignedInt | |||
| usedMoney | Money | |||
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | I | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource |
| identifier:claimnumber | I | 1..1 | Identifier | Claim Number |
| value | ΣI | 1..1 | string | The value that is unique |
| type | ΣI | 1..1 | CodeableConcept | Category or discipline |
| coding | ΣI | 1..1 | Coding | Code defined by a terminology system |
| patient | ΣI | 1..1 | Reference(CARIN BB Patient) | The recipient of the products and services |
| billablePeriod | ΣI | 0..1 | Period | Relevant time frame for the claim |
| insurer | ΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for reimbursement |
| provider | ΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for the claim |
| related | I | 0..* | BackboneElement | Prior or corollary claims |
| relationship | I | 1..1 | CodeableConcept | How the reference claim is related |
| payee | I | 0..1 | BackboneElement | Recipient of benefits payable |
| type | I | 1..1 | CodeableConcept | Category of recipient |
| party | I | 1..1 | Reference(CARIN BB PractitionerRole | CARIN BB Patient) | Recipient reference |
| careTeam | I | 0..* | BackboneElement | Care Team members |
| provider | I | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization |
| responsible | I | 0..1 | boolean | Indicator of the lead practitioner |
| role | I | 1..1 | CodeableConcept | Function within the team |
| supportingInfo | I | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:$this |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 0..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:billingnetworkcontractingstatus | I | 0..1 | BackboneElement | Claim performing provider network status |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 1..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:attendingnetworkcontractingstatus | I | 0..1 | BackboneElement | Claim attending provider network status |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 1..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:referringnetworkcontractingstatus | I | 0..1 | BackboneElement | Claim attending provider network status |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 1..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:clmrecvddate | I | 0..1 | BackboneElement | Claim Received Date |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 0..1 | CodeableConcept | Type of information |
| timing[x] | I | 1..1 | date | When it occurred |
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:typeofbill | I | 0..1 | BackboneElement | Type of Bill |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 0..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:pointoforigin | I | 0..1 | BackboneElement | Claim Point of Origin for Admission or Visit |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 0..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:admtype | I | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 0..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:discharge-status | I | 0..1 | BackboneElement | Discharge Status |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 0..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:ms-drg | I | 0..1 | BackboneElement | Claim diagnosis related group (DRG), including the code system, the DRG version and the code value |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information |
| code | I | 0..1 | CodeableConcept | Type of information |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| diagnosis | I | 1..* | BackboneElement | Pertinent diagnosis information |
| diagnosis[x] | I | 1..1 | (Slice Definition) | Nature of illness or problem Slice: Unordered, Closed by type:$this |
| type | I | 1..1 | CodeableConcept | Timing or nature of the diagnosis |
| onAdmission | I | 0..1 | CodeableConcept | Present on admission |
| procedure | I | 0..* | BackboneElement | Clinical procedures performed |
| type | I | 0..* | CodeableConcept | Category of Procedure |
| date | I | 0..1 | dateTime | When the procedure was performed |
| procedure[x] | I | 1..1 | (Slice Definition) | Specific clinical procedure Slice: Unordered, Closed by type:$this |
| insurance | ΣI | 1..* | BackboneElement | Patient insurance information |
| focal | ΣI | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | ΣI | 1..1 | Reference(CARIN BB Coverage) | Insurance information |
| item | I | 0..* | BackboneElement | Product or service provided |
| adjudication | I | 0..* | (Slice Definition) | Adjudication details Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| category | I | 1..1 | CodeableConcept | Type of adjudication information |
| adjudication:adjudicationamounttype | I | 0..* | BackboneElement | Amounts |
| category | I | 1..1 | CodeableConcept | Type of adjudication information |
| adjudication:denialreason | I | 0..1 | BackboneElement | Denial Reason |
| category | I | 1..1 | CodeableConcept | Type of adjudication information |
| adjudication:allowedunits | I | 0..1 | BackboneElement | Allowed number of units |
| category | I | 1..1 | CodeableConcept | Type of adjudication information |
| adjudication | I | 1..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| category | I | 1..1 | CodeableConcept | Type of adjudication information |
| adjudication:adjudicationamounttype | I | 0..* | BackboneElement | Amounts |
| adjudication:denialreason | I | 0..1 | BackboneElement | Denial Reason |
| adjudication:inoutnetwork | I | 1..1 | BackboneElement | Benefit Payment Status |
| payment | I | 0..1 | BackboneElement | Payment Details |
| Documentation for this format | ||||
This structure is derived from CARINBBExplanationOfBenefit
Summary
Mandatory: 5 elements (8 nested mandatory elements)
Must-Support: 6 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CARINBBExplanationOfBenefit
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource | |
| type | 1..1 | CodeableConcept | Category or discipline | |
| coding | S | 1..1 | Coding | Code defined by a terminology system |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: institutional | |
| provider | 1..1 | Reference(CARIN BB Organization) | Party responsible for the claim | |
| careTeam | 0..* | BackboneElement | Care Team members | |
| role | 1..1 | CodeableConcept | Function within the team Binding: Payer - Inpatient Facility Provider Role (required) | |
| supportingInfo | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:$this | |
| supportingInfo:billingnetworkcontractingstatus | 0..1 | BackboneElement | Claim performing provider network status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: billingnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) | |
| supportingInfo:attendingnetworkcontractingstatus | 0..1 | BackboneElement | Claim attending provider network status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: attendingnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) | |
| supportingInfo:referringnetworkcontractingstatus | 0..1 | BackboneElement | Claim attending provider network status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: referringnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) | |
| supportingInfo:clmrecvddate | 0..1 | BackboneElement | Claim Received Date | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: clmrecvddate | |
| timing[x] | 1..1 | date | When it occurred | |
| supportingInfo:typeofbill | 0..1 | BackboneElement | Type of Bill | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: typeofbill | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Type of Bill (required) | |
| supportingInfo:pointoforigin | 0..1 | BackboneElement | Claim Point of Origin for Admission or Visit | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: admsrc | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Point of Origin of Admission (required) | |
| supportingInfo:admtype | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: admtype | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) | |
| supportingInfo:discharge-status | 0..1 | BackboneElement | Discharge Status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: discharge-status | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) | |
| supportingInfo:ms-drg | 0..1 | BackboneElement | Claim diagnosis related group (DRG), including the code system, the DRG version and the code value | |
| category | 1..1 | CodeableConcept | Classification of the supplied information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: ms-drg | |
| code | 0..1 | CodeableConcept | Type of information Binding: MS-DRG (required) | |
| diagnosis | S | 1..* | BackboneElement | Pertinent diagnosis information |
| diagnosis[x] | S | 1..1 | (Slice Definition) | Nature of illness or problem Slice: Unordered, Open by type:$this |
| diagnosisCodeableConcept | 0..1 | CodeableConcept | Nature of illness or problem Binding: ICD-10-CM Diagnosis Codes (required) | |
| type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | S | 0..1 | CodeableConcept | Present on admission Binding: NUBC Present On Admission (required) |
| item | 0..* | BackboneElement | Product or service provided | |
| revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: NUBC Revenue Code (required) | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: AMA CPT and CMS HCPCS Procedure Codes (required) | |
| modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: AMA CPT and CMS HCPCS Modifier Codes (required) | |
| adjudication | 0..* | (Slice Definition) | Adjudication details Slice: Unordered, Closed by pattern:$this | |
| adjudication:adjudicationamounttype | 0..* | BackboneElement | Amounts | |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Value Codes (required) | |
| amount | 1..1 | Money | Monetary amount | |
| adjudication:denialreason | 0..1 | BackboneElement | Denial Reason | |
| category | 1..1 | CodeableConcept | Type of adjudication information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: denialreason | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) | |
| adjudication:allowedunits | 0..1 | BackboneElement | Allowed number of units | |
| category | 1..1 | CodeableConcept | Type of adjudication information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: allowedunits | |
| adjudication | 1..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by pattern:$this | |
| adjudication:All Slices | Content/Rules for all slices | |||
| category | S | 1..1 | CodeableConcept | Type of adjudication information |
| adjudication:adjudicationamounttype | 0..* | BackboneElement | Amounts | |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Value Codes (required) | |
| amount | 1..1 | Money | Monetary amount | |
| adjudication:denialreason | 0..1 | BackboneElement | Denial Reason | |
| category | 1..1 | CodeableConcept | Type of adjudication information | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: denialreason | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) | |
| adjudication:inoutnetwork | 1..1 | BackboneElement | Benefit Payment Status | |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Benefit Payment Status (required) | |
| coding | 0..* | Coding | Code defined by a terminology system | |
| code | 0..1 | code | Symbol in syntax defined by the system Required Pattern: inoutnetwork | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | I | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| versionId | ΣI | 0..1 | id | Version specific identifier |
| lastUpdated | SΣI | 1..1 | instant | When the resource version last changed |
| source | ΣI | 0..1 | uri | Identifies where the resource comes from |
| profile | SΣI | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| security | ΣI | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible) |
| tag | ΣI | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example) |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | I | 1..* | (Slice Definition) | Business Identifier for the resource Slice: Unordered, Open by pattern:$this |
| identifier:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | SΣI | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | ΣI | 0..1 | string | The value that is unique Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| identifier:claimnumber | SI | 1..1 | Identifier | Claim Number |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: cn | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | The value that is unique Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| status | ?!ΣI | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required) |
| type | SΣI | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: institutional |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| subType | I | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example) |
| use | ΣI | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required) Required Pattern: claim |
| patient | SΣI | 1..1 | Reference(CARIN BB Patient) | The recipient of the products and services |
| billablePeriod | SΣI | 0..1 | Period | Relevant time frame for the claim |
| created | ΣI | 1..1 | dateTime | Response creation date |
| enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
| insurer | SΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for reimbursement |
| provider | SΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for the claim |
| priority | I | 0..1 | CodeableConcept | Desired processing urgency Binding: http://terminology.hl7.org/CodeSystem/processpriority (example) |
| fundsReserveRequested | I | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example) |
| fundsReserve | I | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example) |
| related | SI | 0..* | BackboneElement | Prior or corollary claims |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| claim | I | 0..1 | Reference(Claim) | Reference to the related claim |
| relationship | SI | 1..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example) |
| reference | I | 0..1 | Identifier | File or case reference |
| prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products |
| originalPrescription | I | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller |
| payee | SI | 0..1 | BackboneElement | Recipient of benefits payable |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SI | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Code (required) |
| party | SI | 1..1 | Reference(CARIN BB PractitionerRole | CARIN BB Patient) | Recipient reference |
| referral | I | 0..1 | Reference(ServiceRequest) | Treatment Referral |
| facility | I | 0..1 | Reference(Location) | Servicing Facility |
| claim | I | 0..1 | Reference(Claim) | Claim reference |
| claimResponse | I | 0..1 | Reference(ClaimResponse) | Claim response reference |
| outcome | ΣI | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
| disposition | I | 0..1 | string | Disposition Message |
| preAuthRef | I | 0..* | string | Preauthorization reference |
| preAuthRefPeriod | I | 0..* | Period | Preauthorization in-effect period |
| careTeam | SI | 0..* | BackboneElement | Care Team members |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Order of care team |
| provider | SI | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization |
| responsible | SI | 0..1 | boolean | Indicator of the lead practitioner |
| role | SI | 1..1 | CodeableConcept | Function within the team Binding: Payer - Inpatient Facility Provider Role (required) |
| qualification | I | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example) |
| supportingInfo | SI | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:$this |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:billingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Claim performing provider network status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: billingnetworkcontractingstatus |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:attendingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Claim attending provider network status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: attendingnetworkcontractingstatus |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:referringnetworkcontractingstatus | SI | 0..1 | BackboneElement | Claim attending provider network status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: referringnetworkcontractingstatus |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Network Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:clmrecvddate | SI | 0..1 | BackboneElement | Claim Received Date |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: clmrecvddate |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | SI | 1..1 | date | When it occurred |
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:typeofbill | SI | 0..1 | BackboneElement | Type of Bill |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: typeofbill |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Type of Bill (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:pointoforigin | SI | 0..1 | BackboneElement | Claim Point of Origin for Admission or Visit |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: admsrc |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Point of Origin of Admission (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:admtype | SI | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: admtype |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:discharge-status | SI | 0..1 | BackboneElement | Discharge Status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: discharge-status |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:ms-drg | SI | 0..1 | BackboneElement | Claim diagnosis related group (DRG), including the code system, the DRG version and the code value |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | SI | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: ms-drg |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: MS-DRG (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| diagnosis | SI | 1..* | BackboneElement | Pertinent diagnosis information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Diagnosis instance identifier |
| diagnosis[x] | SI | 1..1 | (Slice Definition) | Nature of illness or problem Slice: Unordered, Closed by type:$this Binding: ICD-10Codes (example) |
| diagnosis[x]:diagnosisCodeableConcept | I | 0..1 | CodeableConcept | Nature of illness or problem Binding: ICD-10-CM Diagnosis Codes (required) |
| type | SI | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | SI | 0..1 | CodeableConcept | Present on admission Binding: NUBC Present On Admission (required) |
| packageCode | I | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example) |
| procedure | SI | 0..* | BackboneElement | Clinical procedures performed |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Procedure instance identifier |
| type | SI | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example) |
| date | SI | 0..1 | dateTime | When the procedure was performed |
| procedure[x] | SI | 1..1 | (Slice Definition) | Specific clinical procedure Slice: Unordered, Closed by type:$this Binding: ICD-10ProcedureCodes (example) |
| procedure[x]:procedureCodeableConcept | I | 0..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10-PCS (required) |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| precedence | I | 0..1 | positiveInt | Precedence (primary, secondary, etc.) |
| insurance | SΣI | 1..* | BackboneElement | Patient insurance information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | SΣI | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | SΣI | 1..1 | Reference(CARIN BB Coverage) | Insurance information |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| accident | I | 0..1 | BackboneElement | Details of the event |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| date | I | 0..1 | date | When the incident occurred |
| type | I | 0..1 | CodeableConcept | The nature of the accident Binding: V3 Value SetActIncidentCode (extensible) |
| location[x] | I | 0..1 | Where the event occurred | |
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| item | SI | 0..* | BackboneElement | Product or service provided |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Item instance identifier |
| careTeamSequence | I | 0..* | positiveInt | Applicable care team members |
| diagnosisSequence | I | 0..* | positiveInt | Applicable diagnoses |
| procedureSequence | I | 0..* | positiveInt | Applicable procedures |
| informationSequence | I | 0..* | positiveInt | Applicable exception and supporting information |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: NUBC Revenue Code (required) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: AMA CPT and CMS HCPCS Procedure Codes (required) |
| modifier | I | 0..* | CodeableConcept | Product or service billing modifiers Binding: AMA CPT and CMS HCPCS Modifier Codes (required) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| encounter | I | 0..* | Reference(Encounter) | Encounters related to this billed item |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | SI | 0..* | (Slice Definition) | Adjudication details Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | SI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Value Codes (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 1..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | SI | 0..1 | BackboneElement | Denial Reason |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: denialreason |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:allowedunits | SI | 0..1 | BackboneElement | Allowed number of units |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: allowedunits |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| detail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Detail level adjudication details |
| subDetail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Subdetail level adjudication details |
| addItem | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | I | 0..* | positiveInt | Item sequence number |
| detailSequence | I | 0..* | positiveInt | Detail sequence number |
| subDetailSequence | I | 0..* | positiveInt | Subdetail sequence number |
| provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| detail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| subDetail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| adjudication | SI | 1..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | SI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Value Codes (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 1..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | SI | 0..1 | BackboneElement | Denial Reason |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: denialreason |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:inoutnetwork | SI | 1..1 | BackboneElement | Benefit Payment Status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Benefit Payment Status (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 0..1 | code | Symbol in syntax defined by the system Required Pattern: inoutnetwork |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| total | ΣI | 0..* | BackboneElement | Adjudication totals |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Payer Adjudication Amount Category (extensible) |
| amount | ΣI | 1..1 | Money | Financial total for the category |
| payment | SI | 0..1 | BackboneElement | Payment Details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 0..1 | CodeableConcept | Partial or complete payment Binding: Claim Payment Status Code (required) |
| adjustment | I | 0..1 | Money | Payment adjustment for non-claim issues |
| adjustmentReason | I | 0..1 | CodeableConcept | Explanation for the variance Binding: Adjudication Denial Reason (extensible) |
| date | I | 0..1 | date | Expected date of payment |
| amount | I | 0..1 | Money | Payable amount after adjustment |
| identifier | I | 0..1 | Identifier | Business identifier for the payment |
| formCode | I | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example) |
| form | I | 0..1 | Attachment | Printed reference or actual form |
| processNote | I | 0..* | BackboneElement | Note concerning adjudication |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| number | I | 0..1 | positiveInt | Note instance identifier |
| type | I | 0..1 | code | display | print | printoper Binding: NoteType (required) |
| text | I | 0..1 | string | Note explanatory text |
| language | I | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| benefitPeriod | I | 0..1 | Period | When the benefits are applicable |
| benefitBalance | I | 0..* | BackboneElement | Balance by Benefit Category |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| excluded | I | 0..1 | boolean | Excluded from the plan |
| name | I | 0..1 | string | Short name for the benefit |
| description | I | 0..1 | string | Description of the benefit or services covered |
| network | I | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example) |
| unit | I | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example) |
| term | I | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example) |
| financial | I | 0..* | BackboneElement | Benefit Summary |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example) |
| allowed[x] | I | 0..1 | Benefits allowed | |
| allowedUnsignedInt | unsignedInt | |||
| allowedString | string | |||
| allowedMoney | Money | |||
| used[x] | I | 0..1 | Benefits used | |
| usedUnsignedInt | unsignedInt | |||
| usedMoney | Money | |||
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| ExplanationOfBenefit.meta.security | extensible | All Security Labels |
| ExplanationOfBenefit.meta.tag | example | CommonTags |
| ExplanationOfBenefit.language | preferred | CommonLanguages Max Binding: AllLanguages |
| ExplanationOfBenefit.identifier.use | required | IdentifierUse |
| ExplanationOfBenefit.identifier.type | extensible | Identifier Type Codes |
| ExplanationOfBenefit.identifier:claimnumber.use | required | IdentifierUse |
| ExplanationOfBenefit.identifier:claimnumber.type | extensible | Pattern: cn |
| ExplanationOfBenefit.status | required | ExplanationOfBenefitStatus |
| ExplanationOfBenefit.type | required | ClaimTypeCodes |
| ExplanationOfBenefit.subType | example | ExampleClaimSubTypeCodes |
| ExplanationOfBenefit.use | required | Pattern: claim |
| ExplanationOfBenefit.priority | example | http://terminology.hl7.org/CodeSystem/processpriority |
| ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codes |
| ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codes |
| ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodes |
| ExplanationOfBenefit.payee.type | required | ClaimPayeeTypeCodeVS |
| ExplanationOfBenefit.outcome | required | ClaimProcessingCodes |
| ExplanationOfBenefit.careTeam.role | required | PayerInpatientFacilityProviderRoleVSProviderRoleVS |
| ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodes |
| ExplanationOfBenefit.supportingInfo.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodes |
| ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.code | required | ProviderNetworkStatusVS |
| ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.code | required | ProviderNetworkStatusVS |
| ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.code | required | ProviderNetworkStatusVS |
| ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:clmrecvddate.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:clmrecvddate.code | example | ExceptionCodes |
| ExplanationOfBenefit.supportingInfo:clmrecvddate.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:typeofbill.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:typeofbill.code | required | NUBCTypeOfBillVS |
| ExplanationOfBenefit.supportingInfo:typeofbill.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:pointoforigin.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:pointoforigin.code | required | NUBCPointOfOriginVS |
| ExplanationOfBenefit.supportingInfo:pointoforigin.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:admtype.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:admtype.code | required | NUBCPriorityOfAdmissionnVS |
| ExplanationOfBenefit.supportingInfo:admtype.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:discharge-status.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:discharge-status.code | required | NUBCPatientDischargeStatusVS |
| ExplanationOfBenefit.supportingInfo:discharge-status.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:ms-drg.category | required | ClaimInformationCategoryVS |
| ExplanationOfBenefit.supportingInfo:ms-drg.code | required | MSDRGVS |
| ExplanationOfBenefit.supportingInfo:ms-drg.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codes |
| ExplanationOfBenefit.diagnosis.diagnosis[x]:diagnosisCodeableConcept | required | ICD10CMVS |
| ExplanationOfBenefit.diagnosis.type | required | PayerInpatientfacilitydiagnosistype |
| ExplanationOfBenefit.diagnosis.onAdmission | required | NUBCPresentOnAdmissionVS |
| ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes |
| ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodes |
| ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodes |
| ExplanationOfBenefit.procedure.procedure[x]:procedureCodeableConcept | required | ICD10PCSVS |
| ExplanationOfBenefit.accident.type | extensible | v3.ActIncidentCode |
| ExplanationOfBenefit.item.revenue | required | NUBCRevenueCodeVS |
| ExplanationOfBenefit.item.category | example | BenefitCategoryCodes |
| ExplanationOfBenefit.item.productOrService | required | CPTHCPCSProcedureCodeVS |
| ExplanationOfBenefit.item.modifier | required | CPTHCPCSModifierCodeVS |
| ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodes |
| ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodes |
| ExplanationOfBenefit.item.bodySite | example | OralSiteCodes |
| ExplanationOfBenefit.item.subSite | example | SurfaceCodes |
| ExplanationOfBenefit.item.adjudication.category | required | ClaimAdjudicationCategoryVS |
| ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | AdjudicationPayerValueCodesVS |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.item.adjudication:denialreason.category | required | ClaimAdjudicationCategoryVS |
| ExplanationOfBenefit.item.adjudication:denialreason.reason | required | AdjudicationDenialReasonVS |
| ExplanationOfBenefit.item.adjudication:allowedunits.category | required | ClaimAdjudicationCategoryVS |
| ExplanationOfBenefit.item.adjudication:allowedunits.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodes |
| ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodes |
| ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodes |
| ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes |
| ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodes |
| ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes |
| ExplanationOfBenefit.addItem.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodes |
| ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodes |
| ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodes |
| ExplanationOfBenefit.addItem.subSite | example | SurfaceCodes |
| ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.adjudication.category | required | ClaimAdjudicationCategoryVS |
| ExplanationOfBenefit.adjudication.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.category | required | AdjudicationPayerValueCodesVS |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.adjudication:denialreason.category | required | ClaimAdjudicationCategoryVS |
| ExplanationOfBenefit.adjudication:denialreason.reason | required | AdjudicationDenialReasonVS |
| ExplanationOfBenefit.adjudication:inoutnetwork.category | required | BenefitPaymentStatusVS |
| ExplanationOfBenefit.adjudication:inoutnetwork.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.total.category | extensible | PayerAdjudicationAmountCategoryVS |
| ExplanationOfBenefit.payment.type | required | ClaimPaymentStatusCodeVS |
| ExplanationOfBenefit.payment.adjustmentReason | extensible | AdjudicationDenialReasonVS |
| ExplanationOfBenefit.formCode | example | Form Codes |
| ExplanationOfBenefit.processNote.type | required | NoteType |
| ExplanationOfBenefit.processNote.language | preferred | CommonLanguages Max Binding: AllLanguages |
| ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodes |
| ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodes |
| ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodes |
| ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodes |
| ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodes |
| Id | Path | Details | Requirements |
IG © 2020+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#0.1.0 based on FHIR 4.0.1. Generated 2020-07-05
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